Please list any additional insurance info you would like us to have in case of emergency:

TO ADD MORE STUDENTS: CLICK "Add another response" - FOUND JUST BELOW THE FIRST ENTRY

Authorization

I further authorize a representative of PAIDEIA CLASSICAL
EDUCATION, a service of Parent And Child Educational Services (PACES) to take my child for any emergency medical treatment needed during school hours and I will be responsible for the charges incurred.

Parent or legal guardian name:

Additional/Secondary Parent or Guardian:

Date:

Date:

By clicking below, I [we] fully authorize a representative of PAIDEIA Classical Education Service (PACES) to take my child for any emergency medical treatment needed during school hours and I [we] will be responsible for the charges incurred.

I [we] agree and authorize PACES to take my [our] child[ren] for medical treatment in an emergency.

Insurance Card scanned image:

Please Note: In order to complete this form, we will need a copy of your current insurance card(s) to keep on record.Please scan the front and back and upload using the link above. If you don't have access to a scanner, please bring your card(s) to the school and we will make a copy for you.